1
|
Annoni F, Gouvea Bogossian E, Peluso L, Su F, Moreau A, Nobile L, Casu SG, Sterchele ED, Calabro L, Salvagno M, Oddo M, Taccone FS. Ketone Bodies after Cardiac Arrest: A Narrative Review and the Rationale for Use. Cells 2024; 13:784. [PMID: 38727320 PMCID: PMC11083685 DOI: 10.3390/cells13090784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/27/2024] [Accepted: 05/01/2024] [Indexed: 05/13/2024] Open
Abstract
Cardiac arrest survivors suffer the repercussions of anoxic brain injury, a critical factor influencing long-term prognosis. This injury is characterised by profound and enduring metabolic impairment. Ketone bodies, an alternative energetic resource in physiological states such as exercise, fasting, and extended starvation, are avidly taken up and used by the brain. Both the ketogenic diet and exogenous ketone supplementation have been associated with neuroprotective effects across a spectrum of conditions. These include refractory epilepsy, neurodegenerative disorders, cognitive impairment, focal cerebral ischemia, and traumatic brain injuries. Beyond this, ketone bodies possess a plethora of attributes that appear to be particularly favourable after cardiac arrest. These encompass anti-inflammatory effects, the attenuation of oxidative stress, the improvement of mitochondrial function, a glucose-sparing effect, and the enhancement of cardiac function. The aim of this manuscript is to appraise pertinent scientific literature on the topic through a narrative review. We aim to encapsulate the existing evidence and underscore the potential therapeutic value of ketone bodies in the context of cardiac arrest to provide a rationale for their use in forthcoming translational research efforts.
Collapse
Affiliation(s)
- Filippo Annoni
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Department of Anesthesiology and Intensive Care, Humanitas Gavazzeni Hospital, 24125 Bergamo, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20072 Milan, Italy
| | - Fuhong Su
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| | - Anthony Moreau
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| | - Leda Nobile
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
| | - Stefano Giuseppe Casu
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| | - Elda Diletta Sterchele
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
| | - Lorenzo Calabro
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
| | - Michele Salvagno
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
| | - Mauro Oddo
- Medical Directorate for Research, Education and Innovation, Direction Médicale, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, 1011 Lausanne, Switzerland
| | - Fabio Silvio Taccone
- Department of Intensive Care, University Hospital of Brussels (HUB), 1070 Brussels, Belgium
- Experimental Laboratory of Intensive Care, Department of Intensive Care, Free University of Brussels (ULB), 1070 Brussels, Belgium
| |
Collapse
|
2
|
Wongtanasarasin W, Ungrungseesopon N, Phinyo P. Association between Intra-Arrest Blood Glucose Level and Outcomes of Resuscitation at the Emergency Department: A Retrospective Study. J Clin Med 2022; 11:jcm11113067. [PMID: 35683454 PMCID: PMC9181384 DOI: 10.3390/jcm11113067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 05/20/2022] [Accepted: 05/27/2022] [Indexed: 02/07/2023] Open
Abstract
Since current cardiac arrest guidelines do not address the benefit of blood glucose measurement, the ideal ranges and target of blood glucose (BG) levels during cardiac arrest to achieve a better result are warranted. We intended to investigate the associations between intra-arrest BG levels and outcomes of cardiac arrest resuscitation at the emergency department (ED). We conducted a retrospective observational study at a single university hospital. Cardiac arrest patients at the ED between 2017 and 2020 were included. Multivariable logistic regression analysis was performed to examine the associations between intra-arrest BG levels and clinical outcomes. We categorized intra-arrest BG into five groups: <70 mg/dL, 70−99 mg/dL, 100−180 mg/dL, 181−250 mg/dL, and >250 mg/dL. Eight hundred and nineteen patients experienced ED cardiac arrest during the study period. Of all, 385 intra-arrest BG measurements were included in the data analysis. The mean age was 60.4 years. The mean intra-arrest BG level was 171.1 mg/dL, with 64 (16.6%) patients who had intra-arrest BG level below 70 mg/dL and 73 (19.0%) patients who had intra-arrest BG level more than 250 mg/dL. Markedly low (<70 mg/dL) and low (70−99 mg/dL) intra-arrest BG levels were significantly associated with a lower chance of return of spontaneous circulation (ROSC, OR 0.36, 95% CI 0.14−0.99, p = 0.05 and OR 0.33, 95% CI 0.12−0.93, p = 0.04, respectively). For patients who experienced cardiac arrest at the ED, an intra-arrest BG level of less than 100 was inversely correlated with sustained ROSC. Although we could not draw a causal relationship between variables concerning this study design, normalizing intra-arrest BG was shown to result in good clinical outcomes.
Collapse
Affiliation(s)
- Wachira Wongtanasarasin
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA 95817, USA
- Correspondence: ; Tel.: +66-99-270-0493
| | - Nat Ungrungseesopon
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
| | - Phichayut Phinyo
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| |
Collapse
|
3
|
Abramson TM, Bosson N, Whitfield D, Gausche-Hill M, Niemann JT. Elevated prehospital point-of-care glucose is associated with worse neurologic outcome after out-of-hospital cardiac arrest. Resusc Plus 2022; 9:100204. [PMID: 35141573 PMCID: PMC8814821 DOI: 10.1016/j.resplu.2022.100204] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/16/2021] [Accepted: 01/08/2022] [Indexed: 11/29/2022] Open
Abstract
Objectives Hyperglycemia is associated with poor outcomes in critically-ill patients. This has implications for prognostication of patients with out-of-hospital cardiac arrest (OHCA) and for post-resuscitation care. We assessed the association of hyperglycemia, on field point-of-care (POC) testing, with survival and neurologic outcome in patients with return of spontaneous circulation (ROSC) after OHCA. Methods This was a retrospective analysis of data in a regional cardiac care system from April 2011 through December 2017 of adult patients with OHCA and ROSC who had a field POC glucose. Patients were excluded if they were hypoglycemic (glucose <60 mg/dl) or received empiric dextrose. We compared hyperglycemic (glucose >250 mg/dL) with euglycemic (glucose 60–250 mg/dL) patients. Primary outcome was survival to hospital discharge (SHD). Secondary outcome was survival with good neurologic outcome (cerebral performance category 1 or 2 at discharge). We determined the adjusted odds ratios (AORs) for SHD and survival with good neurologic outcome. Results Of 9008 patients with OHCA and ROSC, 6995 patients were included; 1941 (28%) were hyperglycemic and 5054 (72%) were euglycemic. Hyperglycemic patients were more likely to be female, of non-White race, and have an initial non-shockable rhythm compared to euglycemic patients (p < 0.0001 for all). Hyperglycemic patients were less likely to have SHD compared to euglycemic survivors, 24.4% vs 32.9%, risk difference (RD) −8.5% (95 %CI −10.8%, −6.2%), p < 0.0001. Hyperglycemic survivors were also less likely to have good neurologic outcome compared to euglycemic survivors, 57.0% vs 64.6%, RD −7.6% (95 %CI −12.9%, −2.4%), p = 0.004. The AOR for SHD was 0.72 (95 %CI 0.62, 0.85), p < 0.0001 and for good neurologic outcome, 0.70 (95 %CI 0.57, 0.86), p = 0.0005. Conclusion In patients with OHCA, hyperglycemia on field POC glucose was associated with lower survival and worse neurologic outcome.
Collapse
|
4
|
Hagita T, Shiotani S, Toyama N, Tominaga N, Miyazaki H, Ogasawara N. Cardiac gas on immediate postmortem computed tomography after cardiopulmonary resuscitation indicates the progression of anaerobic metabolism. FORENSIC IMAGING 2021. [DOI: 10.1016/j.fri.2021.200446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
5
|
Hernández-Avalos I, Flores-Gasca E, Mota-Rojas D, Casas-Alvarado A, Miranda-Cortés AE, Domínguez-Oliva A. Neurobiology of anesthetic-surgical stress and induced behavioral changes in dogs and cats: A review. Vet World 2021; 14:393-404. [PMID: 33776304 PMCID: PMC7994130 DOI: 10.14202/vetworld.2021.393-404] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 01/08/2021] [Indexed: 12/14/2022] Open
Abstract
The anesthetic-surgical stress response consists of metabolic, neuroendocrine, hemodynamic, immunological, and behavioral adaptations through chemical mediators such as the adrenocorticotropic hormone, growth hormone, antidiuretic hormone, cortisol, aldosterone, angiotensin II, thyroid-stimulating hormone, thyroxine, triiodothyronine, follicle-stimulating hormone, luteinizing hormone, catecholamines, insulin, interleukin (IL)-1, IL-6, tumor necrosis factor-alpha, and prostaglandin E-2. Behavioral changes include adopting the so-called prayer posture, altered facial expressions, hyporexia or anorexia, drowsiness, sleep disorders, restriction of movement, licking or biting the injured area, and vocalizations. Overall, these changes are essential mechanisms to counteract harmful stimuli. However, if uncontrolled surgical stress persists, recovery time may be prolonged, along with increased susceptibility to infections in the post-operative period. This review discusses the neurobiology and most relevant organic responses to pain and anesthetic-surgical stress in dogs and cats. It highlights the role of stress biomarkers and their influence on autonomous and demeanor aspects and emphasizes the importance of understanding and correlating all factors to provide a more accurate assessment of pain and animal welfare in dogs and cats throughout the surgical process.
Collapse
Affiliation(s)
- I Hernández-Avalos
- Department of Biological Sciences, Clinical Pharmacology and Veterinary Anesthesia, Faculty of Higher Studies Cuautitlán, Universidad Nacional Autónoma de México, State of Mexico 54714, Mexico
| | - E Flores-Gasca
- Department of Veterinary Surgery, Faculty of Higher Studies Cuautitlán, Universidad Nacional Autónoma de México, State of Mexico 54714, Mexico
| | - D Mota-Rojas
- Neurophysiology of Pain, Behavior and Assessment of Welfare in Domestic Animals, DPAA, Universidad Autónoma Metropolitana, Mexico City 04960, Mexico
| | - A Casas-Alvarado
- Master in Agricultural Sciences. Animal Welfare, Universidad Autónoma Metropolitana, Mexico City 04960, Mexico
| | - A E Miranda-Cortés
- Department of Biological Sciences, Clinical Pharmacology and Veterinary Anesthesia, Faculty of Higher Studies Cuautitlán, Universidad Nacional Autónoma de México, State of Mexico 54714, Mexico
| | - A Domínguez-Oliva
- Department of Biological Sciences, Clinical Pharmacology and Veterinary Anesthesia, Faculty of Higher Studies Cuautitlán, Universidad Nacional Autónoma de México, State of Mexico 54714, Mexico
| |
Collapse
|
6
|
Zhou D, Li Z, Shi G, Zhou J. Proportion of time spent in blood glucose range 70 to 140 mg/dL is associated with increased survival in patients admitted to ICU after cardiac arrest: A multicenter observational study. Medicine (Baltimore) 2020; 99:e21728. [PMID: 32872055 PMCID: PMC7437796 DOI: 10.1097/md.0000000000021728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The benefit of any specific target range of blood glucose (BG) for post-cardiac arrest (PCA) care remains unknown.We conducted a multicenter retrospective study of prospectively collected data of all cardiac arrest patients admitted to the ICUs between 2014 and 2015. The main exposure was BG metrics during the first 24 hours, including time-weighted mean (TWM) BG, mean BG, admission BG and proportion of time spent in 4 BG ranges (<= 70 mg/dL, 70-140 mg/dL, 140-180 mg/dL and > 180 mg/dL). The primary outcome was hospital mortality. Multivariable logistic regression, Cox proportion hazard models and generalized estimating equation (GEE) models were built to evaluate the association between the different kinds of BG and hospital mortality.2,028 PCA patients from 144 ICUs were included. 14,118 BG measurements during the first 24 hours were extracted. According to TWM-BG, 9 (0%) were classified into the <= 70 mg/dL range, 693 (34%) into the 70 to 140 mg/dL range, 603 (30%) into the 140 to 180 mg/dL range, and 723 (36%) into the > 180 mg/dL range. Compared with BG 70 to 140 mg/dL range, BG 140 to 180 mg/dL range and > 180 mg/dL range were associated with higher hospital mortality probability. Proportion of time spent in the 70 to 140 mg/dL range was associated with good outcome (odds ratio 0.984, CI [0.970, 0.998], P = .022, for per 5% increase in time), and > 180 mg/dL range with poor outcome (odds ratio 1.019, CI [1.009, 1.028], P< .001, for per 5% increase in time). Results of the 3 kinds of statistical models were consistent.The proportion of time spent in BG range 70 to 140 mg/dL is strongly associated with increased hospital survival in PCA patients. Hyperglycemia (> 180 mg/dL) is common in PCA patients and is associated with increased hospital mortality.
Collapse
|
7
|
Goldstein DS. The extended autonomic system, dyshomeostasis, and COVID-19. Clin Auton Res 2020; 30:299-315. [PMID: 32700055 PMCID: PMC7374073 DOI: 10.1007/s10286-020-00714-0] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023]
Abstract
The pandemic viral illness COVID-19 is especially life-threatening in the elderly and in those with any of a variety of chronic medical conditions. This essay explores the possibility that the heightened risk may involve activation of the “extended autonomic system” (EAS). Traditionally, the autonomic nervous system has been viewed as consisting of the sympathetic nervous system, the parasympathetic nervous system, and the enteric nervous system. Over the past century, however, neuroendocrine and neuroimmune systems have come to the fore, justifying expansion of the meaning of “autonomic.” Additional facets include the sympathetic adrenergic system, for which adrenaline is the key effector; the hypothalamic-pituitary-adrenocortical axis; arginine vasopressin (synonymous with anti-diuretic hormone); the renin-angiotensin-aldosterone system, with angiotensin II and aldosterone the main effectors; and cholinergic anti-inflammatory and sympathetic inflammasomal pathways. A hierarchical brain network—the “central autonomic network”—regulates these systems; embedded within it are components of the Chrousos/Gold “stress system.” Acute, coordinated alterations in homeostatic settings (allostasis) can be crucial for surviving stressors such as traumatic hemorrhage, asphyxiation, and sepsis, which throughout human evolution have threatened homeostasis; however, intense or long-term EAS activation may cause harm. While required for appropriate responses in emergencies, EAS activation in the setting of chronically decreased homeostatic efficiencies (dyshomeostasis) may reduce thresholds for induction of destabilizing, lethal vicious cycles. Testable hypotheses derived from these concepts are that biomarkers of EAS activation correlate with clinical and pathophysiologic data and predict outcome in COVID-19 and that treatments targeting specific abnormalities identified in individual patients may be beneficial.
Collapse
Affiliation(s)
- David S Goldstein
- Autonomic Medicine Section, Clinical Neurosciences Program, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, 9000 Rockville Pike MSC-1620, Building 10 Room 8N260, Bethesda, MD, 20892-1620, USA.
| |
Collapse
|
8
|
Koizumi G, Mikura K, Iida T, Kaji M, Hashizume M, Murai N, Kigawa Y, Endo K, Iizaka T, Saiki R, Otsuka F, Sasaki J, Hayashi M, Nagasaka S. Analysis of the Relationships between Multiple Endocrine Hormones and Return of Spontaneous Circulation (ROSC) in Cardiac Arrest Patients: Possible Association of the Serum Free T4 Level with ROSC. Int J Endocrinol 2020; 2020:4168420. [PMID: 33312195 PMCID: PMC7721486 DOI: 10.1155/2020/4168420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 11/12/2020] [Accepted: 11/23/2020] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Endocrine hormones are closely associated with homeostasis, so it is important to clarify hormone secretion dynamics in shock. Few reports, however, have examined the dynamics of endogenous hormone secretion relative to prognosis in cardiac arrest patients. Therefore, to clarify the roles of endocrine hormones in out-of-hospital cardiac arrest (OHCA) patients, the concentrations of anterior pituitary, thyroid, and adrenocortical hormones were measured, and their associations with return of spontaneous circulation (ROSC) were examined. METHODS The subjects were OHCA patients transported to our Emergency Department. In addition to conventional clinical laboratory tests, the following were measured: serum TSH, serum free T3, serum free T4 (F-T4), plasma ACTH, serum cortisol, serum GH, serum IGF-1, plasma aldosterone concentration (PAC), and plasma renin activity. The primary endpoint was the presence or absence of ROSC, and the secondary endpoint was 24-hour survival. RESULTS A total of 29 patients, 17 in the ROSC group and 12 in the non-ROSC group, were studied. There were associations between ROSC and low serum potassium, high F-T4, low cortisol, and low PAC on bivariate analyses. There were associations between ROSC and serum potassium, F-T4, and GH using the step-wise method. On multiple logistic regression analysis, a relationship between ROSC and high serum F-T4 level was identified by both methods. There were also associations between 24-hour survival and both low serum potassium and elevated blood glucose levels. CONCLUSIONS The present findings suggest a possible relationship between the serum F-T4 level and ROSC in OHCA patients. A higher serum F-T4 level might cause an increase in the β-adrenergic response in cardiomyocytes and increased responsiveness to catecholamines and was possibly associated with ROSC.
Collapse
Affiliation(s)
- Go Koizumi
- Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan
| | - Kentaro Mikura
- Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan
| | - Tatsuya Iida
- Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan
| | - Mariko Kaji
- Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan
| | - Mai Hashizume
- Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan
| | - Norimitsu Murai
- Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan
| | - Yasuyoshi Kigawa
- Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan
| | - Kei Endo
- Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan
| | - Toru Iizaka
- Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan
| | - Ryo Saiki
- Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan
| | - Fumiko Otsuka
- Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan
| | - Jun Sasaki
- Department of Critical Care and Emergency Medicine, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan
| | - Munetaka Hayashi
- Department of Critical Care and Emergency Medicine, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan
| | - Shoichiro Nagasaka
- Division of Diabetes, Metabolism and Endocrinology, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa 227-8501, Japan
| |
Collapse
|